128-129 / 138
245,518
EE
EE+SP EE+CH
FAM
EE
EE+SP EE+CH
FAM
Medical &
Vision
Dental
RX Runout
RX
1
Total
Employee
Contribution
Employer
Contribution
PEPM
PMPM
Jan-16
433
42
15
102
641
62
82
176
1,553
2,715
$896,258 $112,836
$0
$349,338
$0
$1,358,432
$159,187 $1,517,619 $1,878,638 $247,090 $1,631,547 $977.22
$558.98
Feb-16
431
42
15
102
641
61
81
177
1,550
2,724 $1,171,183 $101,462
$0
$396,779
$0
$1,669,424
$158,892 $1,828,315 $1,875,182 $246,663 $1,628,520 $1,179.56
$671.19
Mar-16
427
41
16
103
642
62
81
176
1,548
2,710 $1,036,873 $80,530
$0
$430,201
$0
$1,547,604
$158,720 $1,706,324 $1,873,403 $246,902 $1,626,501 $1,102.28
$629.64
Apr-16
425
41
17
101
645
62
81
176
1,548
2,714 $1,377,068 $93,008
$0
$61,317
$0
$1,531,392
$158,697 $1,690,089 $1,872,568 $246,067 $1,626,501 $1,091.79
$622.73
May-16
427
38
18
100
645
61
81
177
1,547
2,711 $1,193,478 $77,872
$0
$413,427
$0
$1,684,777
$158,521 $1,843,297 $1,869,853 $244,361 $1,625,492 $1,191.53
$679.93
Jun-16
416
39
18
104
628
65
79
175
1,524
2,718 $1,258,553 $89,496
$0
$374,398
$0
$1,722,447
$156,534 $1,878,981 $1,849,162 $246,883 $1,602,279 $1,232.93
$691.31
Jul-16
416
39
16
99
591
66
77
170
1,474
2,620 $1,952,316 $120,770
$0
$391,286 ($256,513)
$2,207,859
$151,463 $2,359,322 $1,869,736 $240,334 $1,629,402 $1,600.63
$900.50
Aug-16
413
38
17
100
645
66
79
175
1,533
2,726 $1,055,682 $87,297
$0
$438,271 ($8,806)
$1,572,444
$157,241 $1,729,685 $1,935,676 $243,749 $1,691,926 $1,128.30
$634.51
Sep-16
402
39
18
100
657
62
80
177
1,535
2,730 $1,273,647 $91,868
$0
$353,711 $28,685
$1,747,912
$157,457 $1,905,368 $1,937,671 $243,626 $1,694,046 $1,241.28
$697.94
Oct-16
396
39
18
100
663
62
78
176
1,532
2,723 $1,015,090 $81,468
$0
$376,576 ($11,112)
$1,462,021
$157,092 $1,619,113 $1,932,990 $242,124 $1,690,866 $1,056.86
$594.61
Nov-16
391
39
18
101
667
64
78
179
1,537
2,719
$915,541 $65,251
$0
$220,305 ($8,819)
$1,192,278
$157,711 $1,349,989 $1,940,971 $244,806 $1,696,165 $878.33
$496.50
Dec-16
391
41
16
101
660
67
75
184
1,535
2,725 $2,046,491 $103,812
$0
$555,180 ($132,417)
$2,573,066
$157,666 $2,730,732 $1,941,850 $247,804 $1,694,046 $1,778.98 $1,002.10
TOTAL
4,968
478
202
1,213
7,725
760
952
2,118
18,416
32,535 $15,192,179 $1,105,670
$0
$4,360,788 ($388,982)
$20,269,655
$1,889,181 $22,158,836 $22,777,699
$2,940,409
$19,837,290
YTD Average
1,535
2,711
$1,237
$160
$1,077
$1,205
$682
% Contribution
13%
87%
Loss Ratio
97%
Total Claim Over Spec Agg Spec Reimbursed
Class 2/3
Total
Claimant #1 $763,982 $438,982 $50,000 $249,772
Employee Only
$43.60
$85.68
Claimant #2 $276,781
$0
$0
$0
$43.60 $112.45
Claimant #3 $276,727
$0
$0
$0
$1.00
Claimant #4 $266,266
$0
$0
$0
Claimant #5 $255,330
$0
$0
$0
Claimant #6 $247,514
$0
$0
$0
Claimant #7 $217,018
$0
$0
$0
Claimant #8 $213,137
$0
$0
$0
Claimant #9 $206,888
$0
$0
$0
EE Value
$0.00
EE Premier
$57.28
Claimant #10 $197,548
$0
$0
$0
EE + SP
$460.59 EE + SP
$573.06
Legend
Claimant #11 $183,593
$0
$0
$0
EE + CH
$337.05 EE + CH
$469.89
EE
Claimant #12 $171,421
$0
$0
$0
Family
$484.28 Family
$594.94
EE + SP
Claimant #13 $163,226
$0
$0
$0
EE + CH
Claimant #14 $162,235
$0
$0
$0
FAM
Claimant #15 $153,591
$0
$0
$0
Rx
Claimant #16 $151,339
$0
$0
$0
PEPM
Claimant #17 $137,897
$0
$0
$0
PMPM
Claimant #18 $135,128
$0
$0
$0
Claimant #19 $124,687
$0
$0
$0
Claimant #20 $122,060
$0
$0
$0
Claimant #21 $112,413
$0
$0
$0
Claimant #22 $105,715
$0
$0
$0
Claimant #23 $99,811
$0
$0
$0
Claimant #24 $99,204
$0
$0
$0
Claimant #25 $98,687
$0
$0
$0
Claimant #26 $96,589
$0
$0
$0
Claimant #27 $95,942
$0
$0
$0
Claimant #28 $95,143
$0
$0
$0
Claimant #29 $94,368
$0
$0
$0
Claimant #30 $94,122
$0
$0
$0
Claimant #31 $92,297
$0
$0
$0
Claimant #32 $90,512
$0
$0
$0
Claimant #33 $90,387
$0
$0
$0
Claimant #34 $88,741
$0
$0
$0
Claimant #35 $87,624
$0
$0
$0
Claimant #36 $86,516
$0
$0
$0
Claimant #37 $85,236
$0
$0
$0
Total
$6,039,673 $438,982 $50,000 $249,772
% of YTD Claims 29.8%
Notes:
1) Rx claims include rebates received. For 2016, due to contract negotiation, the rebates were received off-cycle resulting in multiple quarters' rebates being paid on one invoice.
2) The specific claims total excludes $50K in specific claims that will be applied towards the $50K aggregating specific. These amounts will not be reimbursed.
3) The Large Claimant list does not include claims incurred and/or paid outside of the stop loss contract provisions. Member claims of $368,998 incurred in 2015, but paid in 2016 are included in claims totals.
Per Member Per Month
Prescription Drugs
Per Employee Per Month
2016
Employee + Spouse
Employee + Child
EE Cont
Family
Employee
$6.48
2016
$0.33
$1,412.40
PCORI Fee
$1,059.73
PPACA Fees
Trans. Rein. Fee
Total Cost
Monthly
Member
Total
Funding 07/01/16 - 06/30/17
Class 2
$262.50
Class 3
Funding 01/01/16 - 12/31/16
AoA Contribution
ABC Company
G-5200 Account Totals - Medical/Dental/Rx/Vision
EXPERIENCE FOR January 1, 2016 to December 31, 2016
SPECIFIC DEDUCTIBLE $325,000 XYZ Reinsurance (12/12)
MONTH
Expected
Specific
Claims
2
Monthly Funding
$11.19
PBM Interface Fee (PMPM)
Est. Fixed
Costs
$1,009.27
Premier Plan Enrollment
Total Paid Claims
Employee
Total
Value Plan Enrollment
Monthly Paid Claims
Admin
$1,345.14
Claimants over $81,250 (25%)
3
$1.00
$37.96
Family
Class 2
$30.89
Class 3
$250.00
$30.89
Fixed Costs 01/01/16 - 12/31/16
Class 1
Includes$800,000Annual forStaff andPriests
AoA Contribution
Funding 07/01/15 - 06/30/16
Specific
Class 1